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cc APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT JAN 2 1 1601 E. HAZE T ON AVE., STOCKTON, CA I2M!�/SERVICES Telephone (209) 466-6781 F E CI�VlR MITFiL NES PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance N(1.,549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health 2!-District.,---`5— � a)e w0al-k or Ma^'eY Z11, p.s.— pb Address'G�5 li uS Qu�Q sactn,y�!� __ �• City D�f Lot Size PM Owner's Name Weldon Schumacher Address1303 Rivercrate Dar., Lodi Phone 369-7496 Contractor PuryianeeDrillers DrllIftCorddress Pe O. Box, 64 LindenLicense No. 377923 Phone887-3554 '. .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR 171I$. s OTHER ell repair j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - # _. r INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ,�; I `LJ Iridustrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation I;p Dia. of Well Casing rig � ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing JZ a ars &9� Peff Specifications if -N� I l Public 1-1 Other fa Delta Depth of Grout Seal Type of Grout 1^� >CIrrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ate id& H.P. State Work Done_ 91* , Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 5011 II TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I,1 DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet.) PPP Installation will serve: Residence_ Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK" ❑ Type/Mfg Capacity No. Compartments ; PKG. TREATMENT PLT. ❑ Method of Disposal E� Distance to nearest: Well Foundation Property Line I � F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property line I SEEPAGE PITS I 1 Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation �PropeiYy Line DISPOSAL PONDS ❑ , I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica t must call fQr II eq 'ed inspections. Complete drawing on reverse side. si„ fined x�S �Cd --- Title:PresidentDate: RX 12/10/87 I R ZDE4RTENT USE ONLY USE ONLY _p� Application Accepted by Date . � +y " Area 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r t INFO FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. + EH 13-241REV.i/H51EH 14-218 r